Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
CENTRAL OKLAHOMA UNITED METHODIST RETIREMENT FACILITY INC
Employer identification number
73-1292317
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions.
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the supported organization?
................
11g(i)
(ii)
A family member of a person described in (i) above?
......................
11g(ii)
(iii)
A 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of monetary support
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 2
Part II
Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year
(or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (see instructions)
..................
12
13
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here........................................
Section C. Computation of Public Support Percentage
14
Public support percentage for 2012 (line 6, column (f) divided by line 11, column (f))
.........
14
15
Public support percentage for 2011 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2012.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
.......................
b
33 1/3% support test—2011.
If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2012.
If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization
.....................................................
b
10%-facts-and-circumstances test—2011.
If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization
................................................
18
Private foundation.
If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions
.....................................................
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 3
Part III
Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
152,488
67,815
154,534
165,197
160,095
700,129
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
17,634,432
18,126,689
19,620,864
21,117,073
20,839,089
97,338,147
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
17,786,920
18,194,504
19,775,398
21,282,270
20,999,184
98,038,276
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
100,000
108,825
122,537
100,808
432,170
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
100,000
108,825
122,537
100,808
432,170
8
Public support (Subtract line 7c from line 6.)
97,606,106
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2008
(b) 2009
(c) 2010
(d) 2011
(e) 2012
(f) Total
9
Amounts from line 6...
17,786,920
18,194,504
19,775,398
21,282,270
20,999,184
98,038,276
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
427,398
221,486
373,409
476,848
485,912
1,985,053
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
427,398
221,486
373,409
476,848
485,912
1,985,053
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
..
13
Total support. (Add lines 9, 10c, 11, and 12.)..
18,214,318
18,415,990
20,148,807
21,759,118
21,485,096
100,023,329
14
First five years.
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public support percentage for 2012 (line 8, column (f) divided by line 13, column (f))
.........
15
97.580 %
16
Public support percentage from 2011 Schedule A, Part III, line 15
...............
16
97.610 %
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2012 (line 10c, column (f) divided by line 13, column (f))
......
17
2.000 %
18
Investment income percentage from 2011 Schedule A, Part III, line 17
.............
18
2.000 %
19a
33 1/3% support tests—2012.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
........
b
33 1/3% support tests—2011.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
.....
20
Private foundation.
If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2012
Schedule A (Form 990 or 990-EZ) 2012
Page 4
Part IV
Supplemental Information.
Complete this part to provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2012
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2012
Open to Public Inspection
Name of the organization
CENTRAL OKLAHOMA UNITED METHODIST RETIREMENT FACILITY INC
Employer identification number
73-1292317
Identifier
Return Reference
Explanation
FIRST ACCOMPLISHMENT DESCRIPTION
FORM 990, PAGE 2, PART III, LINE 4A
IN THE STATE OF OKLAHOMA, EPWORTH VILLA OFFERS APARTMENT AND COTTAGE-STYLE RESIDENCES, TRADITIONAL ASSISTED LIVING, SPECIALIZED MEMORY CARE ASSISTED LIVING AND SKILLED NURSING SERVICES, HOME HEALTH SERVICES AND HOSPICE SERVICES SERVING APPROXIMATELY 700 RESIDENTS AND PATIENTS IN 2012 WITH A WIDE RANGE OF SERVICES AND EDUCATIONAL AND SPIRITUAL OPPORTUNITIES, AND AREAS TO PRACTICE HOBBIES AND INTEREST ON A BEAUTIFUL 40-ACRE CAMPUS LOCATED IN NORTHERN OKLAHOMA CITY. THE COMMUNITY OFFERS BOTH FEE-FOR SERVICE CONTRACTS AND LIFE CARE CONTRACTS WHERE FEES DO NOT INCREASE SUBSTANTIALLY BASED ON THE LEVEL OF CARE PROVIDED. CHARITY CARE MULTIPLE RESIDENTS RECEIVED FINANCIAL BENEFIT FROM THE BENEVOLENT FUND IN 2012, TOTALING 124,854. COMMUNITY HEALTH IMPROVEMENT SERVICES EPWORTH VILLA CONTINUED ITS PARTNERSHIP WITH THE ARTHRITIS FOUNDATION TO PROVIDE A LOW-IMPACT CLASS FOR SENIOR ADULTS IN THE SURROUNDING COMMUNITY WITH ARTHRITIS EVERY TUESDAY AND THURSDAY. LIFE LINE SCREENINGS, A MOBILE HEALTH SCREENING SERVICE PROVIDING VASCULAR SCREEN SERVICES AND OTHER PREVENTIVE HEALTH SCREENINGS ARE HOSTED TWICE A YEAR AT EPWORTH VILLA, SERVING 100 SENIORS IN THE SURROUNDING COMMUNITY IN 2012. HEALTH PROFESSIONS EDUCATION IN 2012, EPWORTH VILLA'S NURSING STAFF WORKED WITH STUDENTS FROM THE UNIVERSITY OF OKLAHOMA, ROSE STATE COLLEGE, FRANCIS TUTTLE VOTECH, OKLAHOMA UNIVERSITY, ST. PAUL'S, PROVIDING MENTORING PHYSICIANS, NURSING RN, LPN, CNA STUDENTS. EPWORTH VILLA CONTINUES TO SERVE AS A CLINICAL SITE FOR STUDENTS INTERESTED IN WELLNESS HOSTING 700 HOURS ADDITIONALLY OVER 640 HOURS WITH OCCUPATIONAL THERAPY STUDENTS. COMMUNITY BENEFIT OPERATIONS EPWORTH VILLA EMPLOYEES ARE ENCOURAGED TO VOLUNTEER THROUGHOUT THE COMMUNITY. ORGANIZATIONS BENEFITING IN 2012 INCLUDE: THE EDMOND SENIOR CENTER, EDMOND WOMEN'S CLUB, OKLAHOMA CITY ROTARY CLUB, OKLAHOMA CITY ARTS COUNCIL, OKLAHOMA GERONTOLOGICAL NURSING ASSOCIATION, INTERNATIONAL FACILITY MANAGEMENT ASSOCIATION, OKLAHOMA ALLIANCE OF AGING AND GIRL SCOUTS OF OKLAHOMA. IN ADDITION, SEVERAL STAFF MEMBERS GAVE EDUCATIONAL LECTURES AND PRESENTATIONS AT VARIOUS EVENTS. PRESIDENT AND CEO JOHN C. HARNED GAVE SEVERAL PRESENTATIONS THROUGHOUT THE YEAR SPEAKING TO VARIOUS CIVIC AND EDUCATIONAL GROUPS HIGHLIGHTING THE IMPORTANCE OF HEALTHY AGING AND THE POSITIVE IMPACTS OF WELLNESS AND PERSON-CENTERED APPROACH TO LONG-TERM CARE. THE EPWORTH VOLUNTEER PROGRAM FOR RESIDENTS IN 2012 LOGGED OVER 12,550 HOURS OF VOLUNTEERISM ON THE CAMPUS AND OUTSIDE OF THE CAMPUS. EPWORTH VILLA SERVES AS A POLLING PLACE FOR TWO VOTING PRECINCTS AND PROVIDES MEETING SPACES FREE OF CHARGE TO A VARIETY OF COMMUNITY ORGANIZATIONS INCLUDING: GIRL SCOUTS, UNITED METHODIST CHURCH, VARIOUS CHURCH GROUPS AND INVESTMENT CLUBS. EPWORTH VILLA'S ALZHEIMER'S SUPPORT GROUP HAS BEEN MEETING MONTHLY SINCE 2008. THE PARKINSON SUPPORT GROUP HAS BEEN MEETING MONTHLY SINCE 2005. EPWORTH VILLA CONTINUED IT'S PARTNERSHIP WITH AARP TO PROVIDE A SAFE DRIVING CLASS SEMI-ANNUAL FOR SENIOR ADULTS IN THE SURROUNDING COMMUNITY. EPWORTH VILLA RESIDENTS PARTICIPATED IN A GRAND- FRIENDS PROGRAM VOLUNTEERING TIME AND SPENDING IT WITH PRE-SCHOOL AGE CHILDREN. CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS EPWORTH VILLA EMPLOYEES DONATED MORE THAN 1,100 TO THE UNITED WAY IN 2012. OVER FIFTY EMPLOYEES AND RESIDENTS RAISED 11,000 FOR THE ALZHEIMER'S ASSOCIATION MEMORY WALK IN 2012.
ORGANIZATION'S PROCESS USED TO REVIEW FORM 990
FORM 990, PAGE 6, PART VI, LINE 11B
BOARD MEMBERS ARE NOTIFIED OF THE FILING AND OFFERED A COPY OF FORM 990, BUT NO REVIEW WAS OR WILL BE CONDUCTED BY THE BOARD.
ENFORCEMENT OF CONFLICTS POLICY
FORM 990, PAGE 6, PART VI, LINE 12C
THE GOVERNANCE AND DEVELOPMENT COMMITTEE ANNUALLY REVIEWS THAT ALL BOARD MEMBERS AND KEY EMPLOYEES HAVE COMPLETED A CONFLICT OF INTEREST FORM AND A SUMMARY REPORT IS PRESENTED TO THE BOARD OF ANY DISCLOSURES.
COMPENSATION PROCESS FOR TOP OFFICIAL
FORM 990, PAGE 6, PART VI, LINE 15A
THE CEO COMPENSATION COMMITTEE MEETS AT LEAST ANNUALLY TO PREPARE THE CEO'S EMPLOYMENT CONTRACT. THE COMMITTEE UTILIZES OUTSIDE LEGAL COUNSEL AND AT LEAST ONE EXTERNAL COMPARATIVE COMPENSATION SURVEY IN PREPARING THE CEO'S EMPLOYMENT CONTRACT.
GOVERNING DOCUMENTS DISCLOSURE EXPLANATION
FORM 990, PAGE 6, PART VI, LINE 19
GOVERNING DOCUMENTS ARE MADE AVAILABLE UPON REQUEST.
OTHER EXPENSES
FORM 990, PART IX, LINE 24E
MEDICAL SUPPLIES 366,209 0 0 MEDICAL DIRECTOR FEE 305,432 0 0 CONTRACT LABOR 234,216 34,083 0 EQUIPMENT RENTAL & MAINT. 232,059 27,935 0 EXPENDABLE GOODS 145,224 34,180 0 BANK CHARGES 0 128,961 0 TRAINING 63,513 24,578 0 CABLE TELEVISION 75,801 0 0 MISC. EXPENSE 52,146 17,421 0 RECRUITING EXPENSE 0 62,875 0 VEHICLE 60,000 0 0 DUES & SUBSCRIPTIONS 6,261 49,785 0 COMMUNICATIONS 47,824 6,156 0 EMPLOYEE PROGRAM 6,980 43,602 0 DURABLE GOODS 31,992 12,954 0 LINENS & DISHWARE 36,542 0 0 UNIFORM 35,278 1,236 0 CLEANING 31,773 0 0 BAD DEBT 23,522 0 0 SPECIAL EVENTS 0 21,916 0 LICENSE FEE 15,149 5,911 0 CHEMICAL 20,379 0 0 ACTIVITIES 19,739 0 0 TELEPHONE SERVICE 4,084 13,305 0 MEDICAL WASTE 10,451 0 0 CONSULTING 9,081 0 0 VOLUNTEER PROGRAM 333 7,895 0 SECURITY 4,608 0 0 ENTERTAINMENT/PROMOTION 0 3,711 0 FLOWERS & DECORATIONS 2,308 0 0 TREE OF LOVE 404 0 0
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.